When a healthcare provider wishes to appeal a denied Medicare claim (Fee-for-Service), Medicare offers five levels in Part A and Part B appeals process. Five levels areas: First Level: MAC Redetermination, Level Two: Qualified Independent Contractor (QIC) Reconsideration, Level Three: Office of Medicare Hearings and Appeals (OMHA) Disposition, Level Four: Medicare Appeals Council (Council) Review, and Level Five: U.S. District Court Judicial Review. In this blog, we discussed Medicare appeal at the first level i.e., MAC redetermination.
Physicians and other suppliers who do not take assignments on claims have limited appeal rights. Patients may transfer their appeal rights to non-participating providers or suppliers who provide the items or services and don’t otherwise have appeal rights. To transfer appeal rights, the patient and non-participating provider or supplier must complete and sign the Transfer of Appeal Rights Form (CMS-20031). Form CMS-20031 must be completed and signed by the beneficiary and the non-participating physician or supplier to transfer the beneficiary’s appeal rights.
First Level Medicare Appeal
You have to send a redetermination request within 120 days from the date you received Electronic Remittance Advice (ERA)/ Standard Paper Remittance (SPR). You will find instructions on ERA and SPR on how to appeal your Medicare claim. Use the Medicare Redetermination Request Form (CMS-20027), or any written document that has the required appeal elements as stated on the ERA or SPR. Send your appeal to the address mentioned on the ERA or SPR. Every MAC will have portals to submit appeals electronically. You will find that information on ERA or you can visit their website. Attach all supporting documents on your appeal and keep a copy of all appeal documents you send to Medicare. MAC staff uninvolved with the initial claim determination will handle the claim redetermination. MAC will issue their decision within 60 days of the redetermination request receipt date. You will receive this decision via a Medicare Redetermination Notice (MRN). If MAC revises their original decision, your claim will be paid in full and you will receive a revised ERA or SPR.
Appeal Tips
Some of the best practices while filling Medicare appeal are listed below:
- Make all appeal requests in writing.
- Starting at Level 2 or 3, consolidate all similar claims into 1 appeal.
- File requests on time with the appropriate entity.
- Include a copy of the decision letter(s) or claim information issued at prior level(s).
- Include a copy of the demand letter(s) if appealing an overpayment determination.
- If the appeal involves an overpayment determined through sampling and extrapolation, identify all contested sample claims in 1 appeal request and clearly state any sampling methodology challenges.
- Include all relevant supporting documents with your first appeal request.
- Include a copy of the Appointment of Representative Form if the requestor isn’t a party and is representing the appellant.
- Respond promptly to document requests.
Appointing a Representative
You can appoint an individual, including an attorney as your representative during the Medicare appeal process. To appoint a representative, you must complete the Appointment of Representative Form (CMS-1696). This appointment is valid for 1 year from the date the party and appointed representative sign the document and remains valid for the entire appeal duration for which it was filed unless revoked. You can use the appointment for multiple claims or appeals during that year unless the party specifically withdraws the representative’s authority. Once an appointment is filed with an appeal request, the appointment is valid beyond 1 year throughout all administrative appeals process levels for that appeal, unless the party revokes it.
Not all healthcare providers can dedicate their time to studying claim denials and filling Medicare appeals. You can take the help of a medical billing company who could help you in filling Medicare appeals. Medical billing experts from such companies will ensure that all the claims are filed properly which ensures fewer claim denials. Outsourcing to medical billing companies will help in accurate and quicker reimbursements. To know more about our billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226.
FAQs
1. What is the purpose of a MAC redetermination in Medicare appeals?
MAC redetermination is the first level of the Medicare appeals process where providers or beneficiaries can request a review of a denied claim. This appeal is handled by Medicare Administrative Contractor (MAC) staff who were not involved in the original claim decision.
2. How can I request a first-level Medicare appeal?
You can request a MAC redetermination within 120 days of receiving the Electronic Remittance Advice (ERA) or Standard Paper Remittance (SPR). Use the Medicare Redetermination Request Form (CMS-20027) or a written document with the required appeal details and send it to the address provided on your ERA or SPR. You can also submit appeals electronically through the MAC’s portal.
3. What documents should I include in a Medicare redetermination request?
Ensure your appeal includes:
- A completed CMS-20027 form or equivalent written request.
- A copy of the decision letter from the initial claim.
- Relevant supporting documents, such as medical records and billing information.
- The Appointment of Representative Form (CMS-1696), if applicable.
4. What is the timeline for MAC to respond to a redetermination request?
After submitting your redetermination request, the MAC has 60 days to issue a decision. You will receive the outcome through a Medicare Redetermination Notice (MRN). If the decision is favorable, the denied claim will be paid, and you will get a revised ERA or SPR.
5. How can outsourcing to a medical billing company help with Medicare appeals?
Medical billing companies, like Medical Billers and Coders (MBC), provide expert assistance in preparing and submitting Medicare appeals. Their expertise ensures accurate documentation, timely submissions, and fewer claim denials, leading to quicker reimbursements. Contact MBC at info@medicalbillersandcoders.com or 888-357-3226 for more information.
